Provider Demographics
NPI:1467178947
Name:ODUTOLA, TAIWO ODUKOYA (OWNER)
Entity Type:Individual
Prefix:
First Name:TAIWO
Middle Name:ODUKOYA
Last Name:ODUTOLA
Suffix:
Gender:M
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21880 ORRICK AVE
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-3052
Mailing Address - Country:US
Mailing Address - Phone:310-927-2119
Mailing Address - Fax:
Practice Address - Street 1:21880 ORRICK AVE
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-3052
Practice Address - Country:US
Practice Address - Phone:310-927-2119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-17
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95022131363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty